Archive for the ‘diagnostic boundaries’ Category

An article on OCD discusses what disorders are related enough to group together.OCD in some respects differs from the other anxiety disorders in terms of phenomenology, brain circuitry, family history, and treatment response. Instead, it shares features of basic etiology, brain circuitry, and genetics with a group of other related or OCD spectrum disorders. These may include Tourette’s syndrome; body dysmorphic disorder; autism and the developmental disorders; eating disorders, including binge-eating disorder; Huntington’s disorder and Parkinson’s disorder; pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) or Sydenham’s chorea; some of the impulse control disorders; some of the newly emerging compulsive and impulsive disorders; and obsessive-compulsive personality disorder. At issue for the DSM-V is also whether the hoarders that are currently considered a subtype of OCD should be thought of as distinct from OCD and placed into one of the obsessive-compulsive spectrum disorders.

It’s from 2005, but this is the first time I’ve run into spectrum notions that weren’t bipolar or autism-related.

I wish there were some way of sitting in on DSM-V committee meetings. I’d love to watch the process by which people attempt to arrive at a working compromise on What Things Are.

Posted by resonance on October 13, 2007 at 5:22 pm under diagnostic boundaries, ocd.Comments Off on OCD and a whole bunch of other stuff.

I do know that similarity in symptoms doesn’t necessarily mean similarity in etiology (in what causes a disorder). For example, you can have a thyroid problem that looks like a mood disorder, but we know they’re not the same disorders because many people with mood disorders don’t have thyroid problems. And brain damage can mimic psychiatric disorders. Kind of like if you have a bucket chain to put out a fire – the house might burn down because there wasn’t any water, or it might burn down because the people started getting smoke inhalation problems and stopped. Totally different causes, same end result.

I’ve wondered about that with ADD when it occurs in bipolar disorder versus when it does not. Since ADD is so very common in bipolar disorder, maybe it’s a set of symptoms caused by something in the mood/energy brokenness, but caused by something else when there isn’t bipolar disorder. Who knows? I poked through PubMed a little but couldn’t find any speculations on the reason for the comorbidity (in bipolar or in anything else).

Conflating what causes depression with whether behavior is someone’s fault is detrimental to everyone, because confusing science about etiology (and subsequent treatment) with moral judgments about blame confuses the science and confuses public understanding about science, and makes developing appropriate treatment and getting people to use it harder, because in that environment treatments also carry undertones of blame (medication = not to blame, meditation/yoga = to blame somewhat, nebulously-defined “life changes” = it’s your fault and you don’t need medication, rather than seeing all of these as useful, some of them as infeasible for some people at some times, and some of them both feasible and necessary, not necessarily in that order).

It’s very hard to disentangle moral judgments from science in most peoples’ minds, as opposed to working within the framework by trying to reclassify depressed people in terms of whether their depression is biological/real versus situational/to blame. I think the framework is the problem, but I’m not sure there’s a lot we can do about it; finding who deserves blame for their problems is a ubiquitous human thing to do, even when blame does not contribute to solving problems and other things do.

On the other hand, maybe giving people a distinct classification system to channel moral judgments into might help keep those judgments away from etiology. Personally, if we have to have one, I favor a system classifying people into those who are pursuing vs those who are not pursuing effective treatment, as measured by lowered depression, not by whether they’re pursuing a particular kind of treatment. If we’re going to have blame no matter what, we might as well try to channel it into a better, albeit still very imperfect and problematic, path.

I hear these terms used by (for the most part) three sets of people. (Begin anecdotal assertions here.) The first consists of patients who are trying to explain that their problems yes, in fact, are serious enough to require medication, and that they do *not* fall in the (presumably lightweight ) situational/reactive depression category. They’re not necessarily questioning the dichotomy itself, just arguing that they’re on the side that shouldn’t be censured for using medication.

Please go read Mind Hacks’ entry on disorders, rhetoric, and politics. It says some stuff I would like to say, and will say later anyway, but it says it better. I’m working on an entry right now about motives driving people’s distinction between “biological” and “situational” depression.

(This entry brought to you by Panera’s free Internet, which extends out into the parking lot, so I’m publicizing them because I didn’t buy anything. Thank you, Panera.)

Someone on the support forums I help with asked whether people who had their first hypomanic episode on antidepressants were already bipolar, or whether the antidepressants made them bipolar.

It’s an interesting question, and not one we know a definitive answer to. Here are my thoughts on it.
Let’s say we have a pair of identical twins, both of whom have pretty much identical major depressive episodes, without any hypomania. Then, twin A goes on antidepressants and starts having hypomanic episodes that persist even after she discontinues antidepressants. So she has bipolar disorder. If we say she’s always had bipolar disorder, then her twin who never goes on antidepressants and never has hypomanic episodes also (likely) has bipolar disorder, despite not meeting the relevant criteria. So we have a diagnostic problem, because now we can’t tell whether someone has unrevealed bipolar disorder or major depression, short of putting them on antidepressants which is usually a bad idea and will only induce hypomania/mania in 30-40% of people with bipolar disorder, anyway.

As an alternative scenario, perhaps all people who have apparent initial manic/hypomanic responses to antidepressants have actually had them before and just didn’t realize it. This would make everything much simpler, and it’s probably true in a lot of cases, but it sounds a little too simple to be true for everyone. I’ve read a number of studies that look at people whose first episode was a major depressive one versus a manic one, for example.

Another possibility would be to speak of some people with depression as being susceptible to bipolar disorder, which got unfortunately realized after antidepressants. A possibly faulty comparison here is to someone who is mentally healthy until they pull a week of all-nighters, have a psychotic break, and are eventually diagnosed as schizophrenic. We don’t speak of them as always having been schizophrenic. But it may not make sense to compare major depression -> bipolar disorder to mentally healthy -> schizophrenic.

I think this is what the researchers Alex Goodwin and Kaye Jamison have in mind when they talk about having a global category of “manic-depression” that includes both “bipolar disorder” and “recurrent unipolar depression” which there is good reason to believe are related to each other.

Schizoaffective disorder is a less well-known diagnosis than schizophrenia, depression, or bipolar disorder, and it tends to confuse people. It was categorized under schizophrenia in earlier versions of the DSM, but in the current version you have to have a mood episode for a “substantial portion” of the time, as well as having psychotic symptoms outside of a mood episode.

That last bit is important because some people with bipolar disorder have psychotic symptoms during manic periods, and some people with bipolar disorder and some people with major depressive disorder have psychotic symptoms during depression. But (according to the DSM-IV) they don’t have psychotic symptoms outside of mood episodes.

But we don’t know from this what schizoaffective disorder actually is. Is it having both a mood disorder and schizophrenia at the same time? Is it a separate disorder from either? (And what about if your depression isn’t long enough or severe enough to be schizoaffective disorder and you get diagnosed with schizophrenia with comorbid depression? Is that a totally different thing?)

Goodwin and Jamison do a quick review, which I will summarize:

The five major schools of thought are:

a separate disorder (but it doesn’t run in families, so this seems less likely)

“an intermediate form on the continuum of psychosis” (I think this means that if you think of disorders as lying along a continuum of psychosis, like you could think of bipolar symptoms as lying along a continuum of severity, schizoaffective is inbetween schizophrenia and bipolar with psychotic symptoms)

comorbid schizophrenia and depression/bipolar

more severe bipolar

less severe variant of schizophrenia

Another school of thought might be that schizoaffective disorder is actually several different things, which is what they tentatively suggest (we’re a little short on actual research to draw strong conclusions):

People who are primarily manic and less pronouncedly psychotic may have an especially severe form of bipolar disorder (suggested by studies showing that it is more associated with bipolar disorder and has a worse course: Gershon et al, 1982; Coryell et al., 1990).

People who are predominantly psychotic and have less prominent, exclusively depressive symptoms may have a less severe variant of schizophrenia (suggested by studies showing outcomes or neuropsych profiles similar to schizophrenics: Brockington et al, 1980; Tsuang and Coryell, 1993; Evans et al, 1999).

People who have about an equal mix are the unlucky bastards who just happened to get both a mood disorder and schizophrenia. (suggested by the epidemiological prevalence of the disorder being a fraction of a percent, about what you’d expect for those two just happening to co-occur: Kendler et al, 1993, 1996).

Again, this is still speculative and we don’t have enough research to confirm (or deny) it. But it’s pretty interesting, no? Maybe we’ll get a bipolar 0.5 to complement I and II? Since all the love’s been going in the other direction, maybe it’s time the crazier among us got a little more attention. And what kind of “less severe” schizophrenia manages to hit you with something akin to major depressive disorder, yet still be less disabling than regular schizophrenia?

(I wouldn’t exactly call this high-quality – rather, I’d call it “strung-out after work” – but it puts together some of the issues that I’ve been thinking about lately.)

There was recently a news article about researchers finding that 2.4% of americans will have subthreshold bipolar disorder (as they defined it) at some point during their lifetime.

Check this post out, in which the author, whose bio states that he is an academic with clinical experience, starts with that article and works up to arguing that anyone who isn’t bipolar type I should not be receiving long-term medication because “there is scant if any research on what appropriate medication is for bipolar II and there is not a damn bit of research attesting to medication for SBD” (subthreshold bipolar disorder).

I do not think he is an academic with training on the research side of psychology. He also seems to have difficulty understanding that different diagnoses of bipolar disorder almost certainly involve similarities in etiology which are relevant to treatment.

A blogger called Furious Seasons links to “>this article, which says: “People with bipolar disorder not otherwise specified (BD-NOS), sometimes called subthreshold bipolar disorder, have manic and depressive symptoms as well, but they do not meet strict criteria for any specific type of bipolar disorder noted in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), the reference manual for psychiatric disorders. Nonetheless, BD-NOS still can significantly impair those who have it”.

Now, check out his later entry where he/she invites readers to rename SBD, in which he/she states that, in comparison to cyclothymia “SBD is like so totally better! Cyclothymia includes alternating periods of low scale hypomania and low scale depression. But SBD is skipping the depression altogether, so we can focus on people who are chronically productive and medicate them until they put on 100 pounds.”
Many of the people responding are equating hypomania to extra nice happiness, which it can involve, but it may also involve severe irritability, racing thoughts, and lots of other fun things.

There are some very interesting things in all this to write about, but they are not being written about well in the blogs I have seen so far. For example, some questions I’m thinking about (most of which I would answer “no”, but at least I’m still thinking about them):

Are our current, DSM-IV views of abnormality the ones that should define what is normal and abnormal? If not, should something else define them (such as, the subjective perceptions of normal/mentally ill that a particular generation on average grew up with)? Should our diagnostic definitions be open to research finding that a set of people formerly included in “normal” have persistent problems that resemble those of people who are currently included in a diagnosis, and bring that information to attention?

On a related note, should our current rates of diagnosis be the “right” ones? (Or, possibly, our rates from the 90s, or the 80s, or what…) Or should we look at population data to see how many people who would benefit from accurate diagnosis and treatment have not received either? (These issues come up all the time with ADD and autism, and to some extent bipolar II and bipolar disorder in general.)

Should people who don’t have “enough” (for whatever definition of enough) problems not receive diagnoses that will help direct them toward the treatment they need to handle those problems effectively?

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Stuff like this makes me so angry – it’s often seems like a failure to admit that someone really could have severe problems, sometimes combined with a need to gatekeep diagnoses so that nobody less troubled can “get in.” It’s not an exclusive club, it’s a set of labels that can help people, but do not currently label all the people they can help.